30,017 (01/2020)

ACT Search of Records Application

Note: A fee is charged for most searches.

Application details
This application is being made by an: Individual (person) Organisation* Agent †
* To make an application on behalf of an organisation, in addition to the requirements mentioned below you must provide authorisation on a letterhead from
the organisation explicitly stating you have permission to request this information on behalf of the organisation, signed by a person with authority to do so.
† For an agent (the agent) to make an application on behalf of another person (the applicant), this form must be completed by the applicant, who must also provide
a letter authorising the agent to present this form on their behalf. The agent must provide the identification of the applicant (identification requirements mentioned
over the page), in addition to their own identification.

Applicant details - individual (details refer to the person completing the form)
Surname Given name Other names

ARSLAN -
Date of birth Business hours contact number Driver licence number*
27/08/1997 0499155095 5472827
Residential address *Must be completed if requesting a search relating to your driver licence.
5/129 Railway Parade Granville NSW 2142
Email address
aa004215@gmail.com

Applicant details - organisation

Full name of representative Position in organisation

Organisation name Contact number

Organisation address ACN

Email address

Statement of Licence Details

A statement of licence details is only available for your own licence (except where an agent’s authority is accepted).
Please note that separate fees apply for an Address History Statement and Statement of Licence Details.

Address History Statement of Licence Details From

3 yrs 5 yrs 10 yrs All yrs 3 yrs 5 yrs 10 yrs All yrs or Date range: To

Statement of registration details

Statement of registration details Registration number

Copy of inspection certificate Date inspection certificate was submitted

Motor Vehicle Accident - If you need to identify another party involved

Information to identify another party involved in a motor accident may only be disclosed in the following circumstances:
• the request is made by the legal representative or insurance company of the party seeking the information, for the purpose of
pursuing a legal claim; or
• the person whose information is sought agrees to the release of the information.
Only the name, address details and identity of the Motor Accident Injuries Scheme may be released to identify a party to an accident.
By completing and signing this application you are agreeing that you will use the information provided by this search solely for the
purpose of identifying another party involved in an accident in which you were involved.

Office use only

Evidence that request relates to a legal claim provided? Yes No CSO initials

This form continues over the page

Road Transport Authority | PO Box 582 Dickson ACT 2602 | Phone: 13 22 81 Pg 1 of 2
 Confirmation of information
If you are a prospective acquirer of a vehicle, the following information may be confirmed or denied by the Road Transport Authority
(RTA):
Information is required regarding the below:

Surname Given name(s)

Registration number as at (date)

Place a tick against the information you wish to be to be confirmed or denied. CSO to complete
Is the name above recorded as the registered operator? Yes No
Is the vehicle registration current or expired? Current Expired
Is the vehicle recorded as stolen? Yes No
Has the vehicle been issued with a defect notice that remains unrectified? Yes No
Has the vehicle been recorded as being written off? Yes No

Payment method

Cash / Cheque Credit card Client account Total Amount $

Cheque - Cheques must be in Australian dollars and will only be effective means of payment if honoured on presentation.
- Cheques should be made payable to the Road Transport Authority, ACT.
Credit Card - Access Canberra is committed to ensuring your financial details are secure. Due to this we advise against sending your
credit card details in written form. To make a credit card payment (Mastercard or Visa only), please ensure you provide us with your
business hours telephone number. Access Canberra will contact you to arrange payment when your application is being processed.
Alternatively you can submit this application in person and make payment at an Access Canberra Service Centre. For Service Centre
locations, opening hours and acceptable payment methods please visit act.gov.au/accessCBR or phone 13 22 81.

Delivery / Collection details

To be collected in person at Service Centre

Mailed to client (please provide address)

Faxed to client (please provide fax number) ( )

Emailed to client (please provide email address) aa004215@gmail.com

Applicants must provide two forms of accepted proof of identity documents for this application to be processed (at least one must be primary).
To view a list of accepted identity documents visit act.gov.au/POI.

Declaration
I declare that all of the preceding information is true and correct to the best of my knowledge. I have attached all the required documentation
where specified. I am aware that if I knowingly provide false information on this application form I may be prosecuted.
Signature Arslan Date 07 / 05 / 2024

Privacy Statement: The personal information on this form is being collected by Access Canberra (part of the Chief Minister, Treasury and Economic Development
Directorate) for driver licensing purposes as authorised by the Road Transport (Driver Licensing) Act 1999 and for vehicle registration purposes as authorised
by the Road Transport (Vehicle Registration) Act 1999. The information may be used for the administration of driver licensing and vehicle registration legislation
and enforcement. Access Canberra will include your information in its “one client record” so that it can be used in respect of any other dealings that you might
have with it. Information about your identity, which forms part of your one client record, will also be used for administrative purposes, including to confirm
that we are dealing with the correct individual. Your personal information may be used or disclosed to other ACT Government Directorates, Commonwealth,
State and other Territory government agencies, transport authorities, law enforcement and court agencies, authorised by law; the Motor Accident Injuries
Commission; Austroads Ltd; the National Heavy Vehicle Regulator; the National Capital Authority and individuals, their agents or insurers following a report
provided to the police of a motor vehicle accident. If you choose not to provide the personal information requested on this form, we may not be able to process
your request. Personal information for this application is not normally disclosed to overseas recipients unless required by law. You can get more information
about Access Canberra’s privacy policy which explains how it handles your personal information, including how you may access personal information about
yourself, seek correction of your personal information held by Access Canberra or complain about an interference with your privacy from act.gov.au/acprivacy.
Office use only

Proof of identity sighted. Type or documents:

Agent authority collected. CSO name and initials:

If this information is to be returned to a Service Centre via email, provide location:

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